A four-year-old boy died after getting his head stuck in a homemade double stairgate, an inquest was told.
Draco Chapman died on April 23, 2019, weeks after becoming stuck between two stairgates that had been fitted one above the other in a door frame by his mother, Rachel Chapman, at their home in Osbert Close, Norwich, Norfolk.
An inquest before assistant coroner Johanna Thompson at Norfolk Coroner's Court on Tuesday heard that Draco was found injured on April 2, 2019, by one of his older siblings.
He had become stuck in a gap of about six inches between the two stairgates leading to the living room as he tried to climb over.
He was taken to Norwich and Norfolk Hospital where he was placed in an induced coma before being transferred to Addenbrooke's Hospital, in Cambridge, and later a hospice, where he died on April 23.
Dr Roddy O'Donnell, clinical director of the paediatric intensive care unit at Addenbrooke's, said Draco died after suffering neurotic asphyxiation from accidental hanging, and a cardiac respiratory arrest.
He said: "It was clear he had suffered serious and irreversible neurological injury."
The court heard that before his death, Draco had been diagnosed with a heart murmur and Noonan syndrome, a condition which can cause heart defects and developmental delays.
Draco, who was one of six children, all of whom lived with his mother, was being looked after by an older sibling at the time of the incident while his mother was at a parents' evening.
Sergeant Graham Green, of Norfolk Constabulary, told the court in a statement that Draco was found injured by his sister and was taken upstairs by an older brother who carried out CPR on him and called the emergency services before his mother arrived home.
The sergeant said that when he spoke to the oldest boy about the incident, he described Draco as "lifeless, peaceful and a sweet little boy".
Sgt Green added that as he spoke to the child in the living room, he noticed "Fruit Shoots and McDonald's" on the living room floor.
A statement by Mrs Chapman, who was pregnant at the time of Draco's death, described how she arrived home to find what had happened.
She said: "I returned home and expected it to be normal. My oldest child was on the phone to the ambulance screaming that he (Draco) had stopped breathing. I went upstairs to do CPR and the ambulance staff arrived and took over."
Mrs Chapman said she had fitted the stairgates on top of one another to keep her children safe and to stop them climbing over it.
She said: "I was pregnant and agreed with the health visitor that I needed help and she made a referral to social services.
"I struggled but knew I needed help. My oldest would help with the children but I had to accept it had got out of hand.
"On April 2, I fitted the second stairgate to stop them (the children) from getting out of the lounge and on to the stairs. I thought it would act as a door and keep them safe in the lounge.
"The bottom one didn't work as Draco used to climb over it."
Health visitor Helen Thompson told the court in a statement she had visited the family in March 2019 and noted Draco using a toy box to climb over the stairgate.
She said: "The house had a lot of dirty nappies outside the front door and in the living room there were scraps of bread on the floor.
"Draco dragged a bit of plastic to the gate and she said it was a piece of dismantled table which she took apart because the children were using it to climb over the stairgate.
"When we discussed the safety of the stairgate, I said the children need to be supervised to keep them safe."
A member of staff at the nursery Draco attended told the court in a statement that they had offered to help Mrs Chapman after noticing his clothing was dirty, and replacements given to him had not been returned.
She said: "She said she had a huge pile of washing and couldn't get on top of it.
"I had a sense she was very tired and overwhelmed and offered her to bring bags into nursery so we could do it and it would be handled discreetly.
"She never took us up on that. I never had any doubt that she loved her children."
The court heard that Draco's mother was no longer caring for her other children, and the nursery staff member said when she visited her after his death Mrs Chapman said she would do anything to turn back time.
Draco's death was recorded as accidental by the coroner, who said: "The medical cause of death is catastrophic brain injury and asphyxiation by hanging.
"Draco became trapped by his neck while trying to climb over the lower stairgate and as a consequence of becoming trapped between this and the higher stairgate, this caused him to become asphyxiated and caused cardiac arrest."
